Diagnostic and Therapeutic Challenges of Cerebral Venous Thrombosis in SARS-CoV-2 Infection: A Case Report and Review of Literature

Abstract

Headache, a common prodromal symptom of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, can also be a manifestation of cerebral venous thrombosis (CVT), secondary to COVID-19. CVT management continues to evolve, with direct oral anticoagulants (DOACs) emerging as an alternative to warfarin. A 44-year-old Asian female, with no past medical history, presented to the emergency room (ER) with complaints of nonproductive cough and left-sided headache. She denied a history of COVID-19 vaccination, and SARS-CoV-2 testing (with reverse transcriptase-polymerase chain reaction) was positive. Non-contrast computed tomography (CT) of the head revealed left transverse sinus hyperdensity, consistent with dense vein sign, and magnetic resonance venography (MRV) confirmed the presence of thrombus. The initial treatment included subcutaneous enoxaparin with headache resolution, and she was discharged on apixaban. Five weeks later, a non-contrast head CT showed resolution of the dense vein sign and recanalisation of left transverse sinus was seen on MRV. This report has highlighted the need for increased awareness of coagulopathy and thrombotic events, including cerebral venous thrombosis, in patients infected with SARS-CoV-2. Unremitting headache, in context of SARS-CoV-2 infection, should be evaluated with appropriate neurovascular imaging. Controlled studies are required to compare the safety and efficacy of DOACs with warfarin for management of cerebral venous thrombosis.

Readmission After COVID-19 for Late Acute Venous Thrombosis; CASE SERIES and Systematic Review of the Literature

“…However, when COVID-19 and CVT coexist, mortality dramatically rises to 35-45%; this has been attributed to the involvement in deep venous sinuses, raising concerns about the need for early and long-term anticoagulation prophylaxis, even late in the course of the infection, to avoid mortality. 15…”

“…However, when COVID-19 and CVT coexist, mortality dramatically rises to 35-45%; this has been attributed to the involvement in deep venous sinuses, raising concerns about the need for early and long-term anticoagulation prophylaxis, even late in the course of the infection, to avoid mortality. 15 Until now, there is no defined guideline for chronic anticoagulation and antiplatelet measures in COVID-19 patients. The Italian Society for Thrombosis and Hemostasis (SISET) 16 recommends maintaining prophylactic anticoagulation for 7 to 14 days after discharge, but only for patients with persistent risk factors such as BMI >30 kg/m 2 , history of VTE, and active cancer.…”

Intracranial complications of hypercoagulability and superinfection in the setting of COVID-19: illustrative cases

“… 7 Previous COVID-19 reports have presented patients with headaches due to CVST. 8 Mechanisms suggested include systemic inflammation, postinfectious immune-mediated responses, and virus-induced endotheliitis or endotheliopathy. 9 aPLs, as seen in Case 1, have also been a proposed contributor to COVID-19–associated hypercoagulability.…”

Paraganglioma: An Unexpected Diagnosis in a Patient With Cerebral Venous Sinus Thrombosis and SARS-CoV-2 Infection

“…A SARS-CoV-2 infection has been associated with a hypercoagulable state, which is not fully understood; however, some authors propose a mechanism linked to a cytokine storm/cascade of inflammatory events provoked by the viral infection and endothelial damage that leads to the formation of imunothrombus [ 3 , 6 ]. Some markers described in this state were elevation of interleukin-6 (IL-6) (a cytokine with an important role in immune and inflammatory responses) and C-reactive protein (CRP) levels [ 3 ].…”